An evidence-based approach is considered the gold standard for health decision-making. Sometimes, a guideline panel might judge the certainty that the desirable effects of an intervention clearly outweigh its undesirable effects as high, but the body of supportive evidence is indirect. In such cases, the application of the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach for grading the strength of recommendations is inappropriate. Instead, the GRADE Working Group has recommended developing ungraded best or good practice statement (GPS) and developed guidance under which circumsances they would be appropriate.Through an evaluation of COVID-1- related recommendations on the eCOVID Recommendation Map (COVID-19.recmap.org), we found that recommendations qualifying a GPS were widespread. However, guideline developers failed to label them as GPS or transparently report justifications for their development. We identified ways to improve and facilitate the operationalisation and implementation of the GRADE guidance for GPS.Herein, we propose a structured process for the development of GPSs that includes applying a sequential order for the GRADE guidance for developing GPS. This operationalisation considers relevant evidence-to-decision criteria when assessing the net consequences of implementing the statement, and reporting information supporting judgments for each criterion. We also propose a standardised table to facilitate the identification of GPS and reporting of their development. This operationalised guidance, if endorsed by guideline developers, may palliate some of the shortcomings identified. Our proposal may also inform future updates of the GRADE guidance for GPS.

American College of Physicians Philadelphia Pennsylvania USA

Amsterdam University Medical Centers University of Amsterdam Amsterdam Netherlands

Centre de Recherche du Centre Hospitalier Affilié Universitaire de Québec CHA Hôpital de l'Enfant Jésus Université Laval Québec City Québec Canada

Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada

Clinical Pharmacology Department of Medicine Stellenbosch University Cape Town South Africa

Clinical Research Institute American University of Beirut Beirut Lebanon

Cochrane Campbell Global Ageing Partnership London UK

Cochrane Canada Hamilton Ontario Canada

Cochrane Germany Cochrane Germany Foundation Freiburg Germany

Cochrane South Africa South African Medical Research Council Cape Town South Africa

Czech National Centre for Evidence Based Healthcare and Knowledge Translation Institute of Biostatistics and Analyses Masaryk University Brno Czech Republic

Deparatment of Family Medicine University of Ottawa Ottawa Ontario Canada

Department of Anesthesiology and Critical Care Medicine Université Laval Québec City Québec Canada

Department of Biomedical Sciences Humanitas University Humanitas University Milan Italy

Department of Clinical Epidemiology and Public Health Institut d'Investigació Biomèdica Sant Pau IIB Sant Pau Barcelona Spain

Department of Health Product Policy and Standards World Health Organization Geneva Switzerland

Department of Health Research Methods Evidence and Impact McMaster University Hamilton Ontario Canada

Department of HIV Hepatitis and Sexually Transmitted Infections World Health Organization Geneva Switzerland

Department of Internal Medicine American University of Beirut Beirut Lebanon

Department of Medicine McMaster University Hamilton Ontario Canada

Department of Medicine University of Ottawa Faculty of Medicine Ottawa Ontario Canada

Department of Pediatrics Post Graduate Institute of Medical Education and Research Chandigarh Chandigarh India

Iberoamerican Cochrane Center Biomedical Research Institute Sant Pau CIBERESP Barcelona Spain

Instituto de Salud Carlos 3 Agencia de Evaluación de Tecnologías Sanitarias Madrid Spain

Internal Medicine Division of Nephrology and Hypertension University of Kansas School of Medicine Kansas City Kansas USA

Joanna Briggs Institute University of Adelaide Adelaide South Australia Australia

Joint Research Centre European Commission Ispra Lombardia Italy

Medical Center University of Freiburg Institute for Evidence in Medicine Freiburg Germany

Methods Centre Bruyère Research Institute Ottawa Ontario Canada

Michael G DeGroote Cochrane Canada and McMaster GRADE Centres McMaster University Hamilton Ontario Canada

National Institute for Health and Care Excellence London UK

School of Epidemiology and Public Health University of Ottawa Ottawa Ontario Canada

WHO Collaborating Center for Infectious Diseases Research Methods and Recommendations McMaster University Hamilton Ontario Canada

Yealth Network Beijing Yealth Technology Co Ltd Beijing China

doi: 10.1136/bmjebm-2021-111866 PubMed

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